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National Emphysema Treatment Trial examines benefits and costs of lung-volume-reduction surgery for severe emphysema

Lung-volume-reduction surgery has been proposed as a palliative treatment for patients with severe emphysema. The National Emphysema Treatment Trial (NETT), cosponsored by the Agency for Healthcare Research and Quality, the National Heart, Lung, and Blood Institute, and the Centers for Medicare & Medicaid Services, compared the effectiveness and cost-effectiveness of lung-volume-reduction surgery with medical therapy for severe emphysema.

After pulmonary rehabilitation, 1,218 patients at 17 medical centers were randomly assigned to undergo lung-volume-reduction surgery or to receive continued medical treatment. One NETT study recently reported on the surgery's impact on patient survival and exercise capacity. A second NETT study reported on its cost-effectiveness. Both studies are summarized here.

Fishman, A., Martinez, F., Naunheim, K., and others (2003, May). "A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema." New England Journal of Medicine 348, pp. 2059-2073.

Overall, lung-volume-reduction surgery increases the chance of improved exercise capacity, but it does not confer a survival advantage over medical therapy for people with severe emphysema, according to findings from this NETT study. Surgery does yield a survival advantage for patients with both predominantly upper-lobe emphysema and low baseline exercise capacity. However, patients previously reported to be at high risk of death from surgery and those with non-upper-lobe emphysema and high baseline exercise capacity are poor candidates for lung-volume-reduction surgery because of increased mortality and negligible functional gain.

Overall mortality among study patients was 0.11 death per person-year in both the surgery and medical therapy groups. However, after 24 months, exercise capacity (based on a cycle ergometer) had improved by more than 10 W in 15 percent of the surgery patients but in only 3 percent of the medical therapy patients. Among patients with predominantly upper-lobe emphysema and low exercise capacity, mortality was lower in the surgery group than in the medical therapy group. Among patients with non-upper-lobe emphysema and high exercise capacity, mortality was higher in the surgery group than in the medical therapy group.

Ramsey, S.D., Berry, K., Etzioni, R., and others (2003, May). "Cost-effectiveness of lung-volume-reduction surgery for patients with severe emphysema." New England Journal of Medicine 248, pp. 2092-2102.

Lung-volume-reduction surgery for severe emphysema is less cost effective in the short term compared with medical therapy due to the high costs of surgery, the number of adverse clinical outcomes, long periods of hospitalization, and greater number of nursing home admissions during the first few months after surgery, concludes this study.

Investigators used Medicare claims and NETT data to analyze costs for the use of medical care, medications, transportation, and time spent receiving treatment. They determined cost-effectiveness with the use of modeling based on observed trends in survival, cost, and quality of life. When patients with excess mortality and little chance of improved functioning after surgery were excluded, the cost-effectiveness ratio for lung-volume-reduction surgery as compared with medical therapy was $190,000 per quality-adjusted life-year (QALY) gained at 3 years and $53,000 per QALY gained at 10 years.

The cost-effectiveness ratio was better for a subgroup of surgery patients who had predominantly upper-lobe emphysema and low exercise capacity after pulmonary rehabilitation who had lower mortality and better functional status than patients who received medical therapy. The cost-effectiveness ratio in this subgroup was $98,000 per QALY at 3 years and $21,000 at 10 years.

Given its cost and benefits over 3 years of followup, lung volume-reduction surgery is costly relative to medical therapy. The researchers note, however, that the procedure may be cost effective if benefits can be maintained over time.

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